HOW MANY INNOCENT PEOPLE WILL BE MURDERED BY BLACKS TODAY?..........THE LOOTING ACROSS AMERICA is as black as the staggering murder and crime rates of BLACKS ACROSS AMERICA. Black Lives Matter? NO LIFE MATTERS TO BLACKS!

Friday, July 19, 2019

BIG PHARMA SUCKS THE BLOOD OUT OF AMERICA WHILE CONGRESS SUCKS OFF THE BRIBES THEY OFFERED

More fundamental than the individuals involved in these crimes is the social system that produces them. The subordination of the political establishment to the private interests of corporations is not a feature of life that will be changed through lawsuits. Rather, the solution to the opioid crisis lies in the mobilization of the working class to take ownership of the for-profit pharmaceutical companies, drug distributors and the entire healthcare industry in order to provide medical care in the interest of human need, not private profit.

Drug companies poured 76 billion opioid pills into US neighborhoods in just six years

Previously undisclosed drug company data released by the US Drug Enforcement Administration (DEA) has provided the most comprehensive look to date at the nation’s opioid crisis. The database, which traces the path of every single narcotic sold in America—from manufacturer to distributor to pharmacy from 2006 to 2012—has been analyzed in a report by the Washington Post.

The data, along with the history of its delayed release, is remarkable in many ways. First, it confirms in the most concrete terms the criminal role played by drug companies in creating the deadly opioid epidemic that now kills 70,000 people a year in the US. The prescription opioid epidemic alone resulted in nearly 100,000 deaths from 2006 through 2012.

According to the database, throughout the documented six-year period in which the drug epidemic was beginning to spin out of control, drug companies poured 76 billion oxycodone and hydrocodone pain pills into US neighborhoods.

This almost incomprehensible number meant that during these years, the companies distributed enough pills to supply every adult and child in the country with 36 pills each per year.

However, the distribution of the pills was not uniform from state to state or from city to city. The state of Kentucky, for example, was flooded with enough pills to give every person 63.3 pills each per year; South Carolina, 58; and Tennessee, 57.7.

West Virginia, the state with the highest opioid death rate during this period, received enough pills to give every person 66.5 pills each year.

Rural areas hard hit

Rural areas were among the hardest hit. In Norton, Virginia, there were enough pills to provide 306 pills per person a year; Martinsville, Virginia, 242; Mingo County, West Virginia, 203.

During the years covered by the database, 2006 to 2012, annual opioid deaths rose from under 18,000 a year to more than 23,000, with prescription drugs cited as factors in almost half the deaths. The volume of the pills handled by the companies also skyrocketed as the epidemic surged, increasing about 51 percent from 8.4 billion in 2006 to 12.6 billion in 2012.

Since then, overall opioid deaths in the US have skyrocketed. The flooding of markets with prescription drugs, especially in economically depressed areas, spawned increased heroin use and ultimately, along with a number of other factors, led to the current fentanyl crisis that added more than 67,000 to the death toll from 2013 to 2017.

There is no doubt that the top drug

manufacturers and distributors are guilty a

thousand times over for the deaths of

hundreds of thousands of innocent people; for

the incalculable pain and suffering on the

part of those addicted, their children, and their

families; for the economic and social

devastation the crisis has brought to large

swaths of rural America. It has placed an

immense strain on healthcare systems,

social services, and the foster care system.

These companies made billions of dollars off

of human suffering.

Complicity of the political establishment

However, the insidious character of this massive operation extends well beyond the drug manufacturers and drug distributors. The drug manufacturers and distributors were able to carry out this operation only because of critical structural support they received from the highest level of the political establishment.

The data revealed Monday comes from an exclusive database controlled and viewable only by the DEA, a government-controlled body supposedly meant to oversee and police these companies. The information to which this body had access is highly detailed, including the name, DEA registration number, address and business activity of every seller and buyer of a controlled substance in the United States. The database also includes drug codes, transaction dates, and total dosage units and grams of narcotics sold.

It is not only the drug companies who have been fighting to keep this database secret, but the DEA along with the US Department of Justice. The database was only unveiled after a yearlong battle for access to the documents waged by the Washington Post and HD Media. What accounts for this secrecy?

The truth is, as with every major industry, the drug corporations routinely buy off politicians to secure ideal business conditions. The DEA exemplifies the fact that the federal agencies supposedly tasked with policing big business—the Securities and Exchange Commission, the Food and Drug Administration, the Environmental Protection Agency, the Occupational Safety and Health Administration—are under the thumb of the corporations and run political interference for them.

Innumerable facts support this claim. First, despite access to this overwhelming data, over the course of this entire crisis the DEA has taken only the most limited action against these companies, which has resulted in many of them paying a pittance in fees for their crimes.

BLOG: TO ESTABLISH A THIRD TERM FOR LIFE, THE MUSLIM BARACK OBAMA FIRST HAD TO DESTROY MIDDLE-AMERICA. HIS CRONY PLUNDERING BANKSTERS AND HIS SURRENDER OF OUR BORDERS TO NARCOMEX DID THAT.

FOR EIGHT YEARS BARACK OBAMA AND ERIC HOLDER SABOTAGED HOMELAND SECURITY TO EASE MORE MEXICANS OVER OUR BORDERS AND INTO OUR JOBS AND VOTING BOOTHS.

OBAMA NEEDED THESE ILLEGALS TO FINISH OFF THE AMERICAN MIDDLE CLASS, WHAT WAS LEFT OF THEM AFTER OBAMA'S CRONY BANKSTERS' PLUNDER.

“The watchdogs at Judicial Watch discovered documents that reveal how the Obama administration's close coordination with the Mexican government entices Mexicans to hop over the fence and on to the American dole.” Washington Times

The Obama administration’s role

However, even this minimal oversight was too much for the companies and their counterparts in Washington. As the opioid crisis was erupting, the US Congress was working to eviscerate the oversight powers of the DEA, starting in 2014 and culminating in the Ensuring Patient Access and Effective Drug Enforcement Act of 2016, which passed by overwhelming votes in Congress and was signed into law by then-President Barack Obama.

The main purpose of the legislation was to stop the DEA’s Office of Diversion Control from halting drug shipments for unusually large and unexplained sales. For example, when several Walgreens pharmacies in Florida sold more than 1 million opioid pills in a year, compared to a nationwide average of 74,000, the Office of Diversion Control could impose fines and suspend distribution, preventing the drugs from reaching the streets pending the results of an investigation.

The 2016 law effectively ended the ability of the DEA to suspend such orders. Political action committees representing the pharmaceutical industry contributed at least $1.5 million to the 23 lawmakers who sponsored or co-sponsored four versions of the bill. Overall, the drug industry spent $102 million lobbying Congress on the bill and related legislation between 2014 and 2016.

At least 46 investigators and attorneys from the DEA, including 32 directly from the Office of Diversion Control, were hired by the pharmaceutical companies after scrutiny of the drug distributors began in 2014.

The intimate connection between these gigantic corporate monopolies and the institutions of state power revealed in the case of opioid drug distributors is the relationship that prevails across-the-board throughout the capitalist system internationally.

Over the course of the last three years, various lawsuits have been brought against different drug companies. Some have been successful in bringing attention to the issues involved and in securing some monetary retribution from the companies. There are currently dozens of drug companies being sued in federal court in Cleveland by nearly 2,000 cities, towns and counties alleging that they conspired to flood the nation with opioids.

While these efforts rightfully target many of the guilty parties involved in the creation of this crisis, the results of the lawsuits, however “successful,” will ultimately do little to repair the damage done by the drug epidemic over the course of the last decade, let alone make whole the families who have suffered the trauma of losing loved ones.

More fundamental than the individuals involved in these crimes is the social system that produces them. The subordination of the political establishment to the private interests of corporations is not a feature of life that will be changed through lawsuits. Rather, the solution to the opioid crisis lies in the mobilization of the working class to take ownership of the for-profit pharmaceutical companies, drug distributors and the entire healthcare industry in order to provide medical care in the interest of human need, not private profit.

Opioid Crackdown Could Lead To More Drug Company Bankruptcies

BRIAN MANN

Two years ago, the drug company Insys Therapeutics posted a
quarter-billion dollars in annual sales. But the Arizona-based firm's fortunes
plummeted so far that on Monday its leaders declared bankruptcy. It was the
latest fall-out from the nation's prescription opioid epidemic, which has killed
more than 200,000 Americans and triggered hundreds of lawsuits against Big
Pharma.

Insys marketed an opioid pain medication called Subsys that
included fentanyl. It generated tens of millions of dollar in annual sales. But
like other prescription opioids marketed aggressively by the drug industry, it
turned out to be highly addictive.

LAW

Insys Files For Chapter 11, Days After Landmark Opioid
Settlement Of $225 Million

Many of the drug industry's biggest companies are tangled up
in a wave of opioid litigation, including name brand companies Johnson &
Johnson and CVS. It's unlikely large firms will follow Insys' lead and seek
Chapter 11 protection, but smaller firms including Purdue Pharma, the maker of
OxyContin, have already floated the possibility.

Attorneys representing hundreds of communities that hoped to
win compensation from Insys issued a statement Monday saying they'll work to
determine whether the company is actually insolvent. "We will actively
pursue full financial disclosure for Insys and any other defendant that files
for bankruptcy," the plaintiff group said.

NATIONAL

New York Lawsuit Claims Sackler Family Illegally Profited
From Opioid Epidemic

They added that their goal in targeting 21 other drug firms
isn't to put them out of business but to "abate the current opioid
epidemic and seek long-term, sustainable solutions." State and local
officials hope to recoup some of the billions of dollars they've spent
responding to the opioid crisis.

One major state opioid trial is underway now in Oklahoma
against Johnson & Johnson, with a second consolidated trial against other
firms set to begin in October in Ohio. Judge Dan Polster, who's presiding over
that federal case, has urged the parties to reach a settlement so communities
receive some compensation without disrupting the pharmaceutical industry.

Sources tell NPR negotiations are underway but no deal has
been reached.

In all, more than 1,800 state and local governments have
filed opioid-related lawsuits. Penalties and settlements could run into the
tens of billions of dollars, rivaling big tobacco payouts of the 1990s. The
move by Insys came a week after the firm pleaded guilty to felony charges that
it bribed doctors to prescribe its Subys fentanyl medication to patients who
shouldn't have been using it.

The company agreed to pay the federal government $225 million
in penalties. Last month, company founder John Kapoor, once a towering figure
in the drug-tech industry, was found guilty on federal racketeering charges
along with four other Insys executives. The company still faced numerous other
opioid-related lawsuits.

In his statement, Insys CEO Andrew Long, said in a statement
those "legacy legal challenges" contributed to the firm's decision to
enter bankruptcy proceedings.

He said bankruptcy proceedings would allow the company to
negotiate with creditors.

The Mexican Army made
two seizures in Ensenada on August 17 (1,036
pounds of meth, heroin, and fentanyl) and August 18 (1,653 pounds of meth,
fentanyl, and marijuana).

The Mexican Army discovered an active drug lab on August 25 in
Tecate and seized four tons of methamphetamine.

The Mexican Federal
Police seized 350 pounds of methamphetamine in
an active drug lab in Tijuana on August 26.

The Mexican Federal
Police seized 20,000 fentanyl pills in an active
lab in Mexicali on September 10.

The Mexican Federal
Police seized 550 pounds of methamphetamine in
Tijuana on September 12.

The Mexican Army seized 1,055 pounds of methamphetamine
near the Arizona border on September 14.

A.G. JEFF
SESSIONS DEFENDS U.S. BORDERS AGAINST THE DEMOCRAT PARTY AND MEXICO’S INVASION.

"Some
of the most violent criminals at large today are illegal aliens. Yet in
cities where the crime these aliens commit is highest, the police cannot
use the most obvious tool to apprehend them: their immigration status. In
Los Angeles, for example, dozens of members of a ruthless Salvadoran
prison gang have sneaked back into town after having been deported for
such crimes as murder, assault with a deadly weapon, and drug
trafficking." HEATHER MAC DONALD

“Heroin
is not produced in the United States. Every gram of heroin present in the United
States provides unequivocal evidence of a failure of border security because
every gram of heroin was smuggled into the United States. Indeed, this is
precisely a point that Attorney General Jeff Sessions made during his
appearance before the Senate Judiciary Committee hearing on October 18, 2017
when he again raised the need to secure the U.S./Mexican border to protect
American lives.”Michael Cutler …..FrontPageMag.com

A.G. JEFF
SESSIONS DEFENDS U.S. BORDERS AGAINST THE DEMOCRAT PARTY AND MEXICO’S INVASION.

"Some of the most violent criminals at large today are illegal
aliens. Yet in cities where the crime these aliens commit is highest, the
police cannot use the most obvious tool to apprehend them: their
immigration status. In Los Angeles, for example, dozens of members of a
ruthless Salvadoran prison gang have sneaked back into town after having
been deported for such crimes as murder, assault with a deadly weapon, and drug
trafficking." HEATHER MAC DONALD

“Heroin
is not produced in the United States. Every gram of heroin present in the
United States provides unequivocal evidence of a failure of border security
because every gram of heroin was smuggled into the United States. Indeed,
this is precisely a point that Attorney General Jeff Sessions made during his
appearance before the Senate Judiciary Committee hearing on October 18, 2017
when he again raised the need to secure the U.S./Mexican border to protect
American lives.”Michael Cutler …..FrontPageMag.com

CJNG is one of the most powerful cartels in Mexico and the Department of
Justice considers it to be one of the five most dangerous transnational
criminal organizations in the world — responsible for trafficking tons of
cocaine, methamphetamine, and fentanyl-laced heroin into the United States.

… and in exchange we get 40 million Mexican flag
wavers, homelessness, a housing crisis, heroin & opioid crisis and jobs for
legals crisis…. ALL THANKS TO THE DEMOCRAT PARTY

“Thirteen
years after welfare reform, the share of immigrant-headed households (legal and
illegal) with a child (under age 18) using at least one welfare program
continues to be very high. This is partly due to the large share of immigrants
with low levels of education and their resulting low incomes — not their legal
status or an unwillingness to work. The major welfare programs examined in this
report include cash assistance, food assistance, Medicaid, and public and
subsidized housing.” Steven A. Camarota

THE LA
RAZA MEXICAN DRUG CARTELS REMIND AMERICANS (Legals) THAT THERE IS NO (REAL)
BORDER WITH NARCOMEX!

“Heroin is not produced in the United
States. Every gram of heroin present in the United States provides unequivocal
evidence of a failure of border security because every gram of heroin was
smuggled into the United States. Indeed,
this is precisely a point that Attorney General Jeff Sessions made during his
appearance before the Senate Judiciary Committee hearing on October 18, 2017
when he again raised the need to secure the U.S./Mexican border to protect
American lives.” Michael Cutler …..FrontPageMag.com

THE MEXICAN DRUG CARTELS OPERATING IN
AMERICA’S OPEN BORDERS

Overall, in the 2017 Fiscal Year,
officials revealed that a record-breaking 455,000 pounds plus of drugs had
already been seized. In 2016, that number amounted to 443,000 pounds. The 2017
haul is worth an estimated $6.1 billion – BREITBART – JEFF SESSION’S DRUG BUST
ON SAN DIEGO

Federal agents raided Q.T Fashion and numerous other businesses in the
downtown fashion district Wednesday, cracking down on a scheme that cartels are
increasingly relying on to get their profits — from drug sales, kidnappings and
other illegal activities — back to Mexico, authorities said.

Nine people were arrested in raids targeting 75 locations, and $90 million
was seized — $70 million in cash. In one condo, agents found $35 million
stuffed in banker boxes. At a mansion in Bel-Air, they discovered $10 million
in duffel bags.

"Los Angeles has become the epicenter of narco-dollar money laundering
with couriers regularly bringing duffel bags and suitcases full of cash to many
businesses," said Robert E. Dugdale, the assistant U.S. attorney in charge
of federal criminal prosecutions in Los Angeles.

LOS ANGELES: MEXICO’S SECOND LARGEST CITY AND GATEWAY FOR THE LA RAZA HEROIN
CARTELS

“The drug epidemic is the product of capitalism and the
policies of the capitalist parties, both Democrats and
Republicans. There is, first of all, the role of the pharmaceutical
companies, which have amassed huge profits from the
deceptive marketing of opioid pain killers, which they claimed were
not addictive. Prescriptions for opioids such as Percocet, Oxycontin and Vicodin
skyrocketed from 76 million in 1991 to nearly 259 million in 2012. What are the
numbers and profits now?

“While
drug distributors have paid a total of $400 million in fines over the past
10 years, their combined revenue during this same period was over $5
trillion.”

“Opioids
have ravaged families and devastated communities across the country.
Encouraging their open use undermines the rule of law and will do nothing to
quell their continued abuse, let alone the problems underlying mass addiction.”

The
National Institute on Drug Abuse estimates that 72,000 Americans died from drug
overdoses in 2017, up from some 64,000 the previous year and 52,000 the year
before that—a staggering increase with no end in sight. Most involved opioids.

A few
definitions are in order. The term opioid is now used to
include opiates, which are derivatives of the opium poppy, and opioids, which
originally referred only to synthesized drugs that act in the same way as
opiates do. Opium, the sap from the poppy, has been used throughout the world
for thousands of years to treat pain and shortness of breath, suppress cough
and diarrhea, and, maybe most often, simply for its tranquilizing effect. The
active constituent of opium, morphine, was not identified until 1806. Soon a
variety of morphine tinctures became readily available without any social
opprobrium, used, in some accounts, to combat the travails and boredom of
Victorian women. (Thomas Jefferson was also an enthusiast of laudanum, one of
the morphine tinctures.) Heroin, a stronger opiate made from morphine, entered
the market later in the nineteenth century. It wasn’t until the twentieth
century that synthetic or partially synthetic opioids, including fentanyl,
methadone, oxycodone (Percocet), hydrocodone (Vicodin), and hydromorphone
(Dilaudid), were developed.

In 1996 a
new form of oxycodone called OxyContin came on the market, and three recent
books—Beth Macy’s Dopesick, Chris McGreal’s American
Overdose, and Barry Meier’s Pain Killer—blame the opioid
epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated
to be released more slowly and therefore lasts longer. The company claimed that
the drug’s slow release would make it less addictive than ordinary oxycodone,
since the initial euphoria—the high—would be muted. Based on this theory and little
else, the FDA permitted OxyContin to contain twice the usual dose of
oxycodone and carry on the label this statement: “Delayed absorption, as
provided by OxyContin tablets, is believed to reduce the abuse liability of a
drug.” (The FDAofficial who oversaw OxyContin’s approval later got a plum
job at Purdue Pharma.)

The
company launched an extraordinarily aggressive and successful marketing
campaign to convince physicians that they had the holy grail of a nonaddictive
opioid. It sent hundreds of sales representatives to doctors’ offices to tout
OxyContin, and offered doctors dinners and trips to meetings at luxury resorts.
And it paid more than five thousand doctors, pharmacists, and nurses to train
as speakers to tour the country promoting OxyContin. But like all opioids,
OxyContin is addictive. And soon enough, users found that they
could crush the pills or dissolve the coating, then snort the drug like cocaine
or inject it like heroin. Each pill would then become essentially an
instantaneous double dose of oxycodone.

OxyContin almost immediately became a blockbuster—that is, a prescription
drug with annual sales of more than $1 billion. It was widely used not just by
those for whom the prescriptions were written, but by their relatives and
friends. The pills were also sold or stolen or otherwise diverted to street
use. In addition, “pill mills” sprang up, where unethical physicians wrote
innumerable prescriptions for OxyContin and refilled them automatically without
ever seeing the patient. McGreal describes “one of the most productive pill
mills in the country,” which operated in the small town of Williamson, West
Virginia—known locally as “Pilliamson.” The town, he says, “was awash in
pills,” and people came by car and bus to line up at the clinic and cooperating
drugstores. “Investigators calculated that in 2009 alone, the clinic pulled in
$4.6 million in a town with a population of little more than three thousand
people.”

It’s
impossible to know how many new prescriptions were obtained in each of these
ways, but one way or another, OxyContin addiction grew into an epidemic. The
epicenter was central Appalachia, and its victims were mainly white people in
small, economically depressed coal-mining communities in southern West Virginia
and parts of Kentucky, Tennessee, and southwestern Virginia.1

The three
books that focus on Purdue Pharma are in a sense the same book. Barry Meier
first published Pain Killer in 2003. The new edition (released
by a different publisher) is much the same, with some updating and
re-arrangements. The two new books, Dopesick and American
Overdose, cover the same story as it unfolded in the same region of the
country. Both Macy and McGreal refer to the 2003 edition of Meier’s book (but
not the new edition, probably because they could not have known of it at the
time their books were written). All three books are gripping and well written,
with detailed accounts, one after another (perhaps too many), of families
decimated by the epidemic. And they all tell the story of Art Van Zee, a
physician in southwestern Virginia, who in 2000 became aware of the growing
epidemic of OxyContin there and tried heroically to get Purdue Pharma and
the FDA to take responsibility for it.

Purdue
Pharma and the Sackler family that founded it are very hard to defend. By
aggressively marketing OxyContin, even after they knew it was being widely
abused, the family became enormously wealthy. But the FDA was also
guilty. It permitted OxyContin to be sold as a relatively nonaddictive opioid
without good evidence to support that claim, and it should have been obvious
that the pills might be crushed or dissolved to make them even more addictive.
Van Zee, along with Beth Davies, a nun who ran the local substance abuse
clinic, saw Lee County, Virginia, blanketed with OxyContin prescriptions and
watched the deaths mount, particularly among young people. They informed
Purdue, which simply stonewalled. Over the following year, Van Zee devoted
himself completely to the cause, meeting with company and FDAofficials and
testifying before a Senate committee, trying to get Purdue to reformulate the
drug or even withdraw it from the market.

In 2007
Purdue pled guilty to criminal charges of fraudulently marketing OxyContin and
settled for $600 million in fines and penalties. Three executives pled guilty
to misdemeanor charges and were sentenced to four hundred hours of community
service and lesser fines. The company’s fine was trivial in comparison with its
profits from OxyContin. In fact, almost every other major pharmaceutical
company has had to settle both civil and criminal charges of fraudulent
marketing for much more (the record settlement is now GlaxoSmithKline’s $3
billion, for a variety of violations, including falsely promoting drugs and
failing to report safety data). These kinds of fines are just the cost of doing
business. And so it was for Purdue Pharma, although the fraudulent marketing
stopped and a warning was added to the label.

The
problem with these three books, and it’s a big one, is that they treat the
Purdue story as though it were the whole story of the opioid epidemic. But
OxyContin did not give rise to opioid addiction, although it jump-started the
current epidemic. Heroin has been a common street drug ever since it was banned
in 1924. Morphine has also been widely abused.

Nor would
taking OxyContin off the market end the epidemic. The overwhelming majority of
opioid deaths are caused not by OxyContin but by combinations of fentanyl,
heroin, and cocaine, often brought in from China via Mexican cartels, and
frequently taken along with benzodiazepines (such as Valium or Xanax) and
alcohol. These drugs are cheaper and stronger, particularly fentanyl. Fentanyl was
first synthesized in 1960, and soon became widely used as an anesthetic and
powerful painkiller. It is legally manufactured and highly effective when used
appropriately, often for short medical procedures such as colonoscopies. The
illicit production and street use is relatively new, but it is now the main
cause of most opioid-related deaths (nearly 90 percent in Massachusetts).

The
steady increase in opioid deaths after OxyContin came on the market has been
supplanted by a much faster increase starting around 2013, when heroin and
fentanyl use increased dramatically. We now have two epidemics—the overuse of
prescription drugs and the much more deadly and now largely unrelated epidemic
of street drugs. By concentrating on the first, we are closing the barn door
after the horse is long gone.

Efforts to deal with the epidemic have been all over the map—literally.
Possession of illegal drugs (and legal drugs illicitly used) is still a federal
crime, and prisons are still full of people whose only crime was that. But many
states, counties, and cities have begun to regard opioid addiction as a public
health issue, not a police issue. They are opening centers in which people who
seek help are shifted to less powerful opioids like methadone and buprenorphine
(Subutex)—a method known as “medication-assisted treatment,” or MAT.
Naloxone (Narcan), the antidote for an opioid overdose, is now sold over the
counter in almost all states. If used immediately, it can prevent an otherwise
inevitable death from a drug overdose. And drug courts, which may drop criminal
charges in return for an agreement to submit to treatment and monitoring, are
becoming more common.

Nan
Goldin/Marian Goodman Gallery

Nan Goldin: Withdrawal/Quicksand, Berlin/NY, February
2016, 2016

Most
controversial are facilities called “safe injection sites,” or SIFs, where
drug users can come to use drugs without fear of arrest. The staff provides
clean needles to reduce the risk of HIV and hepatitis C infections,
and is prepared to resuscitate addicts who overdose. This approach is called
“harm reduction.” The problem is that addicts must still buy drugs illegally,
and it’s almost impossible to know exactly what is in them.

In a
recent New York Times Op-Ed, the deputy attorney general, Rod
Rosenstein, came down hard on SIFs. He warned that “it is a federal felony
to maintain any location for the purpose of facilitating illicit drug use,” and
that “cities and counties should expect the Department of Justice to meet the
opening of any injection site with swift and aggressive action.” He was
referring to plans to operate SIFs in San Francisco, New York City, and
Seattle, and similar options now being considered by Colorado, Maine,
Massachusetts, and Vermont. Later in the same article, however, he softened, saying
we should “help drug users get treatment and aggressively prosecute criminals
who supply the deadly poison,” suggesting that perhaps he doesn’t believe
simple possession is so bad, after all.

But the
proposed solutions to this epidemic range from the extreme of “lock ’em up” to
“drug abuse is no less a disease than cancer or diabetes” and should therefore
be met with the same solicitude. Ryan Hampton exemplifies the latter view in
his angry book, American Fix. A former drug user himself and now an
impassioned advocate and activist, he insists that drug abuse should be
regarded like other diseases. He doesn’t acknowledge that for most users there
was a moment of choice in becoming addicted that is not the case for people
with cancer or diabetes. After receiving Dilaudid for a painful ankle, Hampton
decided to ask for more, and then more. I think one can make the argument for
sympathy with drug users and for understanding how the quest for drugs ceases
to be under their control without claiming an analogy to diseases like cancer
or diabetes.

Hampton
paints a vivid picture of the downward spiral of addiction. When he “leveled up
to IV heroin,” he explains, “it was cheaper than pills, easier to get
hold of, and a quarter the cost. More important, nobody was tracking us in a
database.”

Where
Hampton is at his best is in his exposure of the profiteering and corruption in
the burgeoning addiction industry—what he calls “the treatment industry swamp.”
In the swamp, he found

lack of
effective treatment, exorbitant costs, and ridiculous twenty-eight-day
vacations disguised as medical help, fed by patient brokers who run a
completely legal, high-end human trafficking cartel to push tens of thousands
of patients through the broken system.

He was
referring to the panoply of treatment centers, both residential and outpatient,
and detox facilities, where users are supposed to be weaned from drugs before
entering “sober living houses.” As in so much of American medicine, even
nonprofit insurers like Medicaid outsource the actual delivery of care to
for-profit companies that charge whatever the market will bear. According to
Hampton, “one of the most expensive treatment centers in America, Passages
Malibu, costs more than $60,000 per month.” Costs are settled by a crazy quilt
of payers, including state and local governments, Medicaid, other federal
programs, private insurers, and often by desperate families. Not surprisingly,
only a minority of users are ever treated.

In 2017 the Aspen Institute’s Health Strategy Group, led by two former
secretaries of health and human services, Tommy Thompson and Kathleen Sebelius,
and consisting of twenty-four members from various health-related fields (I am
among them), met for three days to examine the opioid epidemic. The
deliberations were preceded by four presentations by experts in the field. In
the final broad and comprehensive report, the group made a strong case for
decriminalizing drug addiction and instead regarding it as a public health
issue. Among the five major recommendations was a call for more research into
nearly all aspects of the epidemic. It’s startling how little we know, given
the immensity of the problem and the media attention it receives.2

We need
to know, for instance, how effective opioids are for different kinds of pain,
including long-term treatment for chronic pain. We need to know how opioids
compare in effectiveness and side effects with acetaminophen (which can cause
liver failure) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
(which can cause gastrointestinal bleeding). We need to know how the death rate
in the opioid epidemic compares with the rate of use. We know the death rate is
soaring, but does that mean the rate of use is, too, or is it simply a result
of the lethality of the drug mixtures obtained on the street? We need to know
how much diversion there is now from legitimate treatment to abuse. That
includes diversion of methadone and buprenorphine, which are also opioids and
can be sold on the street or added to the user’s illicit intake. According to
Macy, “Buprenorphine is the third-most-diverted opioid in the country, after
oxycodone and hydrocodone.”

We need
to know how many addicts want to quit, since most don’t seek
treatment. Why don’t they? And finally, we need to know the best approach to
treatment. There is concern, for example, that detox might be dangerous,
because the first dose after a relapse can be deadly if the user is no longer
tolerant to the drug’s effects. Is providing methadone or buprenorphine
indefinitely, even for life, the best treatment among bad choices? There is
plenty of speculation about all of these questions, and suggestive findings
about some of them, but little solid evidence.

We also need to remember an essential and crucial fact: opioids do have a
legitimate purpose, and it’s an enormously important one. They treat severe
pain, often when no other treatment is effective. Patients suffering from
cancer are sometimes completely dependent on opioids for relief, as are some
patients with other forms of severe pain. As the authors of the books
acknowledge, pain was systematically undertreated throughout most of the
twentieth century. After centuries of free and easy use of opioids, there was a
sudden reaction in the United States at the start of the twentieth century,
which had much to do with anti-immigrant sentiment, particularly animus toward
Chinese immigrants who were widely assumed to be opium addicts. (It also
paralleled the growing reaction against alcohol that resulted in Prohibition.)
The 1914 Harrison Narcotics Tax Act imposed strict regulations on the use of
opioids; they had to be prescribed by physicians, and then only for patients
not already taking them. Prohibition lasted for only thirteen years, but the
dread of opioid addiction stayed with us until the 1980s and caused cruel
suffering for generations of patients.

Even in
hospitals where cancer patients lay dying in agony, opioids were administered
reluctantly, in small doses, and at infrequent intervals. When I was in
training in a teaching hospital in the 1960s, there was an awful ritual to it.
The drugs were administered according to a pro re nata (prn)
regimen (ostensibly “as needed”) that required the patient to wait out a
four-hour interval, no matter how severe the pain, and then request the next
dose. Those who badly wanted the drug had to keep track of the time and have
the strength and endurance to summon a nurse if one was nearby. Patients were
sometimes inhibited in asking for the next dose by a desire to please the
medical staff and not be a nuisance, or by their own belief that taking
morphine was somehow wrong or reflected weakness. The extent to which nurses
and physicians shared the common fears of addiction influenced their readiness
to respond. Desperate patients would count the minutes toward the end of the
interval, hoping they could flag down a nurse. Many doctors and nurses
interpreted the anxiety and clock-watching as a sign of growing addiction, not
inadequate pain relief. These patients were labeled “drug-seeking” and often
punished for it by being denied the very help they needed.

During
the 1980s there was a welcome change in that attitude, partly due to the
hospice movement that had begun in the United Kingdom. The prn system
became more flexible, or was eliminated altogether. There was a realization
that because pain is entirely subjective, there is no way to measure or verify
it, and even patients with the same condition could differ in their experience
of pain. Instead of having to flag down nurses, patients were asked at shorter
intervals whether they needed pain relief, and how much. In 2001 the Joint
Commission on the Accreditation of Healthcare Organizations proclaimed pain the
fifth vital sign, to be assessed in every patient, along with heart rate,
respiratory rate, temperature, and blood pressure. Although the motivation for
this move was laudable, it presented problems, since, unlike the other four
vital signs, pain can’t be objectively quantified.

The
authors of the books under review recognize the history of inadequate treatment
of pain throughout most of the twentieth century, but they don’t give it its
due. They concentrate instead on the reaction of the 1980s, which they consider
excessive and an underlying cause of the opioid epidemic. In 1982 I wrote an
editorial in TheNew England Journal of Medicine, which
began, “Few things a doctor does are more important than relieving pain.” I
still believe that. I ended with these words: “Pain is soul-destroying. No
patients should have to endure intense pain unnecessarily. The quality of mercy
is essential to the practice of medicine; here, of all places, it should not be
strained.”

The opioid epidemic, while horrifying, is still outweighed by alcohol
deaths, which are also increasing, according to the Centers for Disease
Control. Hampton writes, “If my first drug of choice came with a prescription,
the second one, alcohol, was culturally embedded and used to celebrate at every
turn of events.” In 2016, when there were 64,000 deaths in the US from the drug
epidemic, there were 90,000 from alcohol (including accidents and homicides
caused by inebriated people, as well as direct effects, mainly cirrhosis of the
liver). Cigarette smoking is estimated to cause 480,000 deaths a year. I do not
intend to minimize the opioid epidemic. Far from it. What I want to underscore
is the differences in these three epidemics. Alcohol and cigarettes have no
medical or practical uses of any kind. Yet we permit their use if regulated. In
contrast, opioids do have medical uses, and they are important.

The
opioid epidemic is usually seen as a supply problem. If we can interdict the
supply of prescription opioids, the thinking goes, we can stanch the epidemic.
But that is unlikely to work for two reasons. First, as I pointed out, this is
no longer mainly an epidemic of prescription drugs but of street drugs. And
second, it creates an onerous obstacle for doctors and outpatients who require
pain treatment. More and more, they have to satisfy regulations expressly
designed to restrict access to prescription opioids. Some make sense. For
example, it’s reasonable to monitor opioid prescriptions to detect pill mills.
It’s also reasonable to flag users who “doctor-shop,” that is, see several
doctors at once to try to get multiple doses of opioids.

But other
requirements are meant simply to inconvenience both doctors and patients until
they give up. For example, in Massachusetts doctors must limit their first-time
opioid prescriptions to seven days. That can be more than an inconvenience for
ill patients in pain. Macy quotes a letter from a friend with severe back pain
from scoliosis. “‘My life is not less important than that of an addict,’ my
friend wrote,…explaining that her new practitioner requires her to submit to
pill counts, lower-dose prescriptions, and more frequent visits for refills,
which increase her out-of-pocket expense.” Even more serious is a new shortage
of opioids for injection in cancer centers.

For
physicians, who are already weighed down by innumerable bureaucratic
requirements, these restrictions present one more hoop to jump through, and
many simply won’t do it. Instead, they’ll send the patient away with some Advil
and hope it does the trick, even though they know it probably won’t. The
regulations are having their intended effect. In Massachusetts, opioid
prescribing has decreased by 30 percent. Meanwhile, the epidemic of street
drugs continues apace. McGreal raises the possibility that reducing access to
prescription opioids might feed the demand for heroin. Macy quotes an addiction
specialist who laments that “our wacky culture can’t seem to do anything in a
nuanced way.”

I believe the modern opioid epidemic is now more a demand problem than a
supply problem. Three years ago, the Princeton economists Anne Case and Angus
Deaton published an explosive paper about the surprising rise in mortality,
starting at the turn of this century, among middle-aged white non-Hispanic men
and women. The increase was greater in women than in men. They found three main
causes: drug and alcohol overdoses, suicide, and alcohol-associated liver
disease. They later called these “deaths of despair,” because they were most
common among workers in tenuous jobs, with only a high school education or
less, who were struggling to stay afloat in isolated regions of the country.
Dragged down by these deaths, in the past three years overall life expectancy
in the United States has started to drop.

It’s not
hard to see reasons for the despair. Most working-class Americans have not
benefited from our booming economy, the fruits of which have gone almost
entirely to the richest 10 percent. For the bottom half of the population,
income has scarcely budged since the 1970s, while expenses for necessities like
housing, health care, education, and child care have skyrocketed. In
Appalachia, where the opioid epidemic first took hold, many coal miners were
unemployed and would probably remain so. People expected they wouldn’t live as
well as their parents had, and had little hope for their children. It is true
that African-Americans still have higher overall mortality rates than whites,
but that gap is closing rapidly for people under the age of sixty-five, particularly
for women. By 2027, white women will have higher mortality rates than
African-American women. Mortality for African-American men is falling even
faster than for African-American women; it is projected to be equal to that of
white men by 2030. But the epidemic has extended to all parts of the country
and to all ethnic groups, so it’s unclear how the effects will be distributed
in the future.

By the
middle of this decade, the grotesque inequality in this country began to get
the attention it deserves. And the growing awareness of that inequality fed the
populist passion that, when twisted and distorted, produced the election of
Donald J. Trump. It’s probably not coincidental, then, that the opioid epidemic
got its second wind at about that time. It certainly marks the time when the
opioids of choice changed from prescription drugs to the witches’ brew of
street drugs. Did the epidemic explode because people were becoming aware that
the American Dream was no longer theirs to dream?

As long
as this country tolerates the chasm between the rich and the poor, and fails
even to pretend to provide for the most basic needs of our citizens, such as
health care, education, and child care, some people will want to use drugs to
escape. This increasingly seems to me not a legal or medical problem, nor even
a public health problem. It’s a political problem. We need a government
dedicated to policies that will narrow the gap between the rich and the poor
and ensure basic services for everyone. To end the epidemic of deaths of
despair, we need to target the sources of the despair.